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Information on record keeping

Summary

Once you are registered with us, you have a professional responsibility to keep full, clear and accurate records. This is so you can:

share information as required with colleagues;

ensure service users receive appropriate treatment that is in their best interests;

meet legal requirements, or respond to Freedom of Information or Subject Access Requests; and

evidence their decision-making processes if later queried or investigated.

The style and structure of the records you keep will depend on your profession. For this reason, more information should be available from your professional body or employer (as opposed to from us).

You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to; (10.1)‘You must complete all records promptly and as soon as possible after providing care, treatment or other services’ (10.2)‘You must keep records secure by protecting them from loss, damage or inappropriate access’ (10.3) Standards of conduct, performance and ethics

Resources for record keeping

The Information Commissioner’s Office (ICO) is the UK authority on information rights and data protection. Registrants should refer to their guide to data protection and the data protection principles.

The IGA have also produced a retention schedule which sets recommendations for how long records should be retained, either due to their ongoing administrative value or as a result of statutory requirement.

The Scottish Government published their Records Management: NHS Code of Practice in 2008. This includes minimum NHS retention periods in Annex D. These vary from those applicable in England and stipulate:

Basic retention period for adult records of 6 years after date of last entry or 3 years after death if earlier;

20 years or 3 years after death for persons classified as mentally disordered until the Mental Health Act.

Although the codes and guidance set out above are typically concerned with practices within the NHS, these documents should help inform the approach private practitioners should take.

Social care records, where a local authority is the provider, must be managed in accordance with the requirement to make proper arrangements under Section 224 of the Local Government Act 1972. Local arrangements are likely to apply.

About our guidance

We work on the principle of ‘professional self-regulation’. This means you have a personal responsibility to maintain and manage your own fitness to practise.

Our standards of conduct, performance and ethics set out the criteria that all our registrants must meet. Within them, our requirements are outlined. To help registrants meet these we’ve produced additional material, like this page.